Anne-Marie C. Dingemans, MD, PhD, Department of Pulmonology, Maastricht University Medical Center, Maastricht, Netherlands
As the relative importance of chemotherapy in NSCLC management is changing, how can chemotherapeutic agents contribute to increasing efficacy in the context of new treatments?
Over the last years, the treatment of lung cancer patients has improved greatly due to the introduction of new drugs such as targeted agents and immunotherapies. However, all of the data show that these treatments do not work for all patients. Therefore, we still need chemotherapy. For example, chemotherapy can be necessary to induce a systemic response in patients with driver mutations at the time of multiple resistance after several lines of treatment. We have also seen in the area of immunotherapy that a proportion of these patients do not respond at all or do not respond very rapidly. Chemotherapy can be very helpful in patients with a low PD-L1 expression or in those with a high burden of disease and especially a high symptom burden, who are in need of a rapid response.
Will chemotherapy be replaced completely in the long run?
No, I do not think so. We need chemotherapy together with radiotherapy, and we need chemotherapy when rapid responses are required in a patient. It is always being said that immunotherapies have fewer side effects. Indeed, this is true for grade 3/4 adverse events on a numerical level. However, with chemotherapy, grade 3/4 toxicity mainly consists of neutropenia, the burden of which is not very severe for the patient. Also, these side effects are short-lived. Rare side effects of immunotherapies can be long-lived, and the patient can have long-term problems. Therefore, I think that we will always need chemotherapy as a combination partner, particularly together with radiotherapy, and in patients for whom no targeted agents are available.
What combination of chemotherapeutic agents with other drug classes do appear promising at present?
Combinations of chemotherapy with immunotherapy appear promising, although we need to determine what types of chemotherapy are ideal for this, because it is not known whether every combination has the same efficacy. For example, it might be possible to administer chemotherapy regimens that do not contain platinum, and thus toxicity could be diminished. This might be an interesting focus of research.
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